Precision and Accuracy of a Digital Impression Scanner in

Full-Arch Implant Rehabilitation

Paolo Pesce, DDS, PhD1/Francesco Pera, DDS, PhD2/Paolo Setti, DDS3/Maria Menini, DDS, PhD4

Purpose: To evaluate the accuracy and precision of a digital scanner used to scan four
implants positioned according to an immediate loading implant protocol and to assess the
accuracy of an aluminum framework fabricated from a digital impression. Materials and
Methods: Five master casts reproducing different edentulous maxillae with four tilted implants
were used. Four scan bodies were screwed onto the low-profile abutments, and a digital
intraoral scanner was used to perform five digital impressions of each master cast. To assess
trueness, a metal framework of the best digital impression was produced with computer-
aided design/computer-assisted manufacture (CAD/CAM) technology and passive fit was
assessed with the Sheffield test. Gaps between the frameworks and the implant analogs were
measured with a stereomicroscope. To assess precision, three-dimensional (3D) point cloud
processing software was used to measure the deviations between the five digital impressions
of each cast by producing a color map. The deviation values were grouped in three classes,
and differences were assessed between class 2 (representing lower discrepancies) and the
assembled classes 1 and 3 (representing the higher negative and positive discrepancies,
respectively). Results: The frameworks showed a mean gap of < 30 μm (range: 2 to 47 μm).
A statistically significant difference was found between the two groups by the 3D point cloud
software, with higher frequencies of points in class 2 than in grouped classes 1 and 3 (P < .001).
Conclusion: Within the limits of this in vitro study, it appears that a digital impression may
represent a reliable method for fabricating full-arch implant frameworks with good passive fit
when tilted implants are present. Int J Prosthodont 2018;31:171–175. doi: 10.11607/ijp.5535

T he accuracy of intraoral impressions is critical for

fabricating a precise definitive or master cast, on
which the prosthesis will be created.1 Heckmann et al
report that 50% of errors in terms of precision are due
to the impression technique performed by the clini-
cian, whereas the remaining 50% are related to inac-
curate laboratory procedures.2
In implant dentistry, the passive fit of an
implant-supported fixed prosthesis is mandatory to
ensure a correct and successful oral rehabilitation,
especially in cases of immediate placement and
loading of implants. 3 Misfit of an implant prosthesis
1Research Fellow, Department of Surgical Sciences (DISC), Implant and
Prosthetic Dentistry Unit, University of Genoa, Genoa, Italy.
2Lecturer, Department of Surgical Sciences (DISC), Implant and Prosthetic
Dentistry Unit, University of Genoa, Genoa, Italy.
3PhD Student, Department of Surgical Sciences (DISC), Implant and
Prosthetic Dentistry Unit, University of Genoa, Genoa, Italy.
4Assistant Professor, Department of Surgical Sciences (DISC), Implant and
Prosthetic Dentistry Unit, University of Genoa, Genoa, Italy.
Correspondence to: Dr Paolo Pesce, Department of Surgical Sciences
(DISC) Implant and Prosthetic Dentistry Unit (PAD. 4),
Ospedale S. Martino, L. Rosanna Benzi 10, 16132 Genova, Italy.
Fax: + 39 0103537402. Email: paolo.pesce@unige.it
©2018 by Quintessence Publishing Co Inc.
due to an inaccurate impression may induce both
mechanical (eg, fracture of prosthesis and/or im-
plant system components and loosening of the
prosthetic retaining screws) and biologic compli-
cations (eg, failure of osseointegration, marginal
bone loss, pain, and soft tissue inflammation).1,4
Currently, two different impression techniques are
primarily used in implant prosthodontics: the indirect
technique and the direct technique.3 Both are rela-
tively difficult to perform, time consuming, operator
sensitive, and have proven to be uncomfortable for
patients. During recent years, intraoral digital impres-
sion systems have gained acceptance due to high ac-
curacy and ease of use and have been incorporated
into the fabrication of dental implant restorations to
overcome these problems. The use of intraoral digital
impressions enables the clinician to produce accurate
restorations without some of the unpleasant aspects
of traditional impression materials and techniques,5
namely long implant transfers (which require wide
mouth opening, especially in the posterior areas) and
light impression material (which is barely tolerated
by patients, particularly in those affected by incoerc-
ible gag reflex or with difficulty opening the mouth).
Moreover, some laboratory steps (ie, cast realization)
can be skipped entirely.

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Digital Impression Scanner for Full-Arch Implant Rehabilitation
Fig 1   The five casts used for the in vitro investigation and the aluminum frameworks realized on the base
of the most complete impression.
A previous in vitro study by the same team of au-
thors6 compared traditional and digital impression
techniques using a simplified model with multiple im-
plants. The intraoral scanner appeared to be a viable
alternative to traditional impressions, using different
materials and techniques (open-tray, closed-tray, and
splinting of impression copings with resin). Similar re-
sults were obtained by another group of researchers,
who concluded that digital full-arch implant impres-
sions were significantly more accurate than conven-
tional impressions.7
In 2015, Ender and Mehl8 introduced the terms
“trueness” and “precision” as different measures of
accuracy. Trueness is defined as the comparison be-
tween a control STL dataset and a test STL dataset.
Precision is defined as a comparison between differ-
ent datasets obtained using the same digital scanner.
In light of the previous outcomes and definitions, the
aims of the present study were (1) to assess the preci-
sion of a dental scanner used to scan models repro-
ducing real clinical situations including tilted implants
using prototype scan bodies; and (2) to assess the fit
of a metal framework produced from a digital impres-
sion with computer-aided design/computer-assisted
manufacture (CAD/CAM) technology.
172 The International Journal of Prosthodontics
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Materials and Methods
Five master casts made with plaster type 4 (Fujirock
EP, GC) were poured, reproducing five different eden-
tulous maxillae with four tilted implants rehabilitated
according to the Columbus Bridge Protocol9 (Fig 1).
The implants presented different inclinations and dif-
ferent inter-implant distances (range: 13 to 27 mm).
Four implant low-profile analogs (diameter 4 mm;
low-profile abutment non-hexed temporary cylinder,
Biomet3i) were used (Fig 1). Four prototype scan
bodies designed by Simbiosi were screwed onto the
low-profile abutments. The scan bodies (Fig 2) had
a cylindrical body with semi-spherical extremities
aimed at a more precise digital repositioning of the
scan bodies themselves. They have been specifically
designed for edentulous patients because they are
shorter than the usual scan bodies to allow for easier
impression taking, even at the distal implants.
An intraoral scanner system (True Definition Scanner,
3M ESPE) was used to perform five digital impressions
of each master cast (total of 25 digital impressions). Five
different operators who had never used an intraoral
scanner before were selected and participated in a day
of training with the digitizing system before the start of

Fig 2   Specially designed scan bodies.
the study. The training session undertaken was com-
prised of a 4-hour explanation of the system and its
application followed by 4 hours of practice using a
test cast. The clinicians complied with a defined pro-
tocol: before taking the impression, four scan bodies
were screwed onto the implant analogs; subsequent-
ly, the cast was powdered with a homogenous layer
of dust (3M High-Resolution Scanning Spray, 3M
ESPE) for scanning procedures. The scanning proce-
dure started from implant 26 and proceeded in con-
tinuous mode, making circular movements, around
all the scan bodies. This differed in comparison to the
technique described by Gimenez et al,7 allowing a
faster digital impression process. The entire digitizing
process had to be performed in less than 7 minutes.
At the end of the impression procedure, the operat-
ing system confirmed the suitability of the scan or
highlighted the need to repeat the scan in order to
acquire missing or incorrectly digitized areas.
Fit Assessment
Sheffield Test. For each master cast, the best digi-
tal impression was identified according to three pa-
rameters: (1) presence of scattering; (2) complete
at the scan body level; and (3) file dimension (to
facilitate the software in the repositioning process).
This impression was used as a control impression
for evaluating both trueness and precision. The
control impressions were used to fabricate five alu-
minum frameworks with CAD/CAM technology in
a specialized laboratory (Simbiosi). Passive fit was
assessed with the Sheffield test, screwing each
framework onto the corresponding master cast.
According to this test, a framework is considered
well fitting if it is possible to tighten a single screw
on a distal model abutment without creating a gap
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Pesce et al
Fig 3   Digital reproduction of the model and color scale, indicating the
value of discrepancy compared to the control impression (the red color
indicates extreme positive values and the blue color indicates extreme
negative values; green points were the most accurate).
Table 1   D
 iscrepancy Values Subdivided into Three
Classes, with Class 2 Representing Smaller
Deviation from the Reference Impression
Class Class start (μm) Class end (μm)
1 –0.099895410240 –0.024934630841
2 –0.024934630841 0.025039222091
3 0.025039222091 0.100000001490
between the other framework-analog interfaces. If the fit
is not sufficient, the superstructure will be lifted when a
screw is tightened, creating a gap at the level of one or
more abutment analogs.10,11
A stereomicroscope [Wild M3Z, Wild Heerbrugg] with
×40 magnification was used to record the value of gaps
at the framework-abutment analog interfaces (on the
vestibular side). Eight measurements were recorded for
each metal framework: four screwing the framework at
implant site 2.6, and another four screwing the frame-
work at implant site 1.6.
Precision Assessment
Superimposition Test. Impressions taken with the
True Definition scanner were imported with a 3D
point cloud (and triangular mesh) processing software
(Cloudcompare, Danielgm.net). All five digital impres-
sions for each model were analyzed to perform com-
parisons between 3D point clouds. The best selected
impression for each model, as described above, was
compared with the other four impressions. The soft-
ware produced a color map demonstrating the size of
the deviations between the control impression and the
other impressions (Fig 3). Values of discrepancies were
grouped in three classes (Table 1).
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Digital Impression Scanner for Full-Arch Implant Rehabilitation

Table 2   S
 heffield Test Findings for Mean, Standard use of an intraoral scanner represents a viable
Deviation (SD), Minimum (Min), and Maximum alternative to traditional impression materials for
(Max) Gap Values for the Five Models
the fabrication of full-arch, implant-supported
Framework Mean ± SD (μm) Min (μm) Max (μm) prostheses provided with a satisfactory passive
Model 1 24 ± 19 3 44 fit. In particular, comparing the impression with a
Model 2 22 ± 14 3 47 reference image obtained with a 3D Coordinate
Model 3 27 ± 15 3 45 Measurement Machine (CMM), they found that
Model 4 21 ± 12 3 37
the digital impression performed the best, while
traditional techniques revealed a greater variability
Model 5 21 ± 16 2 46
in the results. It seems that traditional techniques
presented a greater risk of error. The purpose of
the present study was therefore to assess in vitro
Table 3   O
 verall Differences Between Class 2 and
the precision of digital implant impressions of com-
Grouped Classes 1 and 3 plete-arch restorations with tilted implants using
Group Mean SD Median Minimum Maximum
prototype scan bodies and a simplified methodol-
ogy compared to previous studies.
Class 2 33,459.4 4,488.5 32,041.5 28,931.0 41,904.0
According to the present results, all the frame-
Classes 3,587.4 3,512.5 2,550.5 167.0 11,141.0 works presented a vestibular gap of < 47 μm as
1 and 3
evaluated in the Sheffield test. Jemt and Lie14 de-
P ≤ .001
fined the passive fit as an accuracy level that does
not cause any long-term clinical complications and
discrepancies of up to 150 μm as acceptable. In
addition, the superimposition test showed great
Statistical Analysis precision of the five impressions performed by five
different clinicians for each cast: The higher fre-
A statistical analysis was performed comparing the quencies of points were found in class 2, represent-
number of points included in each class of discrepancy. ing a gap between –0.025 and 0.025 μm. Moreover,
Descriptive analysis was reported as mean and stan- it must be underlined that points in classes 1 and
dard deviation (SD) and median with range (minimum 3 were not at the scan body level, but only in the
to maximum). gingival area; in fact, the greatest differences be-
Statistical tests were performed using SPSS v 20 tween the five impressions were at gingival level,
(IBM). Class 2 (representing lower discrepancies) fre- and some of the clinicians did not take a complete
quencies were compared with the other assembled impression of all the gingiva. On the contrary, all
groups (1 and 3) using nonparametric Mann-Whitney U clinicians focused their attention at the scan body
test. P ≤ .05 was considered statistically significant. level, which is the most important part for the real-
ization of the framework.
Results In the present study, the fits of milled frame-
works were tested in a more clinical way compared
The findings of the Sheffield test are reported in Table 2. to other papers in which a coordinate-measuring
The frameworks showed a mean gap value < 30 μm machine (CMM) was used.7 Clinicians cannot use
(range: 2 to 47 μm). a CMM inside the mouth to test trueness; the only
A statistically significant difference regarding preci- exam clinically possible to test framework precision
sion was found between the two groups, with higher fre- is the Sheffield test. The results of the Sheffield test
quencies of points in class 2 (lower discrepancies) than in the present study showed that with a full digital
in the other classes (1 and 3) (P < .001) (Table 3). process (digital impression, best-fit repositioning,
milled framework), the same precision as with the
Discussion classic impression technique can be obtained but
in a faster way, even in the challenging situation
The accuracy and rigidity of prosthodontic frameworks reproduced in the present study, where implants
have been reported to be fundamental prerequisites for with different angulations were used in full-arch
the predictable osseointegration of dental implants for rehabilitations.
immediate loading.12,13 Given the increasing interest in these devices,
In a previous study, Menini et al6 evaluated the ac- several studies have been published in recent
curacy of different impression techniques (traditional years testing the accuracy of different intra-
vs digital) on multiple implants. They reported that the oral scanners. However, only a few articles have

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investigated the use of digital impressions in full-arch
rehabilitations supported by multiple implants.6,15,16
Vandeweghe et al evaluated the accuracy of four in-
traoral scanners used for implant impressions in the
edentulous jaw and found that there was a significant
difference in accuracy between the different scan-
ners: One intraoral scanner did not achieve the nec-
essary level of accuracy to be used for large-span,
implant-supported reconstructions, while the other
scanners (including the one used in the present
study) demonstrated an acceptable level of trueness
and precision for this indication.15 Chew et al com-
pared the 3D accuracy of conventional direct implant
impressions with digital implant impressions from
three intraoral scanners and found that the conven-
tional impression group had significantly lower dis-
tortion than the digital impression groups.16
This research presents several limitations in simu-
lating the clinical situation, mainly the inability to
reproduce the oral environment in terms of tempera-
ture, humidity, and the patient’s movements. Despite
this, the use of master casts enabled minimal impact
of confounding factors, such as patient movements
and patient-dependent variability.
The use of only one digital scanner is another limita-
tion of the present work. However, the True Definition
Scanner was chosen because of its performances in
other studies.7,15–17 Another limit may be represented
by the inexperience in the digital scanning procedure
of the five operators; however, the results suggest that
even with very limited experience, it is possible to ob-
tain satisfactory impressions using a digital scanner.
Conclusions
Within the limits of this study, digital impressions
obtained with the True Definition Scanner represent
a reliable method for fabricating full-arch implant
frameworks with good passive fit in the presence of
tilted implants.
Acknowledgments
The authors wish to thank Odt Fabio Ferri (Professional Service
3M), 3M-ESPE, and Simbiosi for their support of the present re-
search. The authors declare no conflicts of interest regarding the
publication of this paper.
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Pesce et al
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